Healthcare Provider Details

I. General information

NPI: 1033845680
Provider Name (Legal Business Name): JACKIELINE PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 MORENA BLVD STE 200
SAN DIEGO CA
92110-3850
US

IV. Provider business mailing address

1260 MORENA BLVD STE 200
SAN DIEGO CA
92110-3850
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-3261
  • Fax: 619-275-2023
Mailing address:
  • Phone: 619-398-3261
  • Fax: 619-275-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number165484
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: